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Case Report

Sampaio Fernandes et al.

CAD-CAM all-ceramic fully sintered zirconia


crowns for the oral rehabilitation of an
amelogenesis imperfecta case
Coroas CAD-CAM de zircnia totalmente sinterizada para
reabilitao oral de um caso de amelogenesis imperfecta

Abstract
Purpose: To present a case report of a patient with amelogenesis imperfecta rehabilitated with
26 CAD-CAM all-ceramic fully sintered zirconia crowns.
Case description: A male subject, 28 year-old, sought dental treatment presenting a clinical
condition compatible with amelogenesis imperfecta. All teeth had yellow, brown, and white
areas of weak enamel. Composite restorations were present on teeth 14, 16, 24, 25, 26,
27, and 46; dental caries were shown on teeth 36, 37, and 47. Hipersensitivity was reported.
The treatment included fully sintered zirconia crowns for all teeth, using a CAD-CAM system.
No problems of marginal adaptation of the crowns were detected, and the final results were
satisfactory for both the patient and the clinician.
Conclusion: The clinical rehabilitation of an amelogenesis imperfecta case is a challenge, and
a multidisciplinary approach is required. Zirconia all-ceramics crowns are an excellent option
to restore dental aesthetics as the opaque zirconia coping can mask dischromic abutments,
and the crowns have biocompatibility and improved physical properties.

Joo Carlos Sampaio Fernandes a


Andr Ricardo Maia Correia b
Jorge Andr Cardoso a
Pedro Ferrs da Silva Fernandes a
Tiago Coutinho Almeida a
Miguel Gonalves Pinto c

a
Discipline of Fixed Prosthodontics, Faculty of
Dental Medicine of University of Porto, Porto,
Portugal
b Discipline of Anatomy, Faculty of Dental Medicine
of University of Porto, Porto, Portugal
c Department of Periodontology, Faculty of Dental
Medicine of University of Porto, Porto, Portugal

Key words: Crowns; amelogenesis imperfect; yttria-stabilized tetragonal zirconia polycrystals


ceramic; dental esthetics

Resumo
Objetivo: Apresentar o caso clnico de um paciente com amelogenesis imperfecta, que foi
reabilitado com 26 coroas CAD-CAM de zircnia totalmente sinterizada.
Descrio do caso: Um sujeito do sexo masculino, 28 anos, procurou tratamento odontolgico
apresentando uma condio clnica compatvel com amelogenesis imperfecta. Todos os dentes
tinham reas amarelas, marrons e brancas de esmalte enfraquecido. Havia restauraes de
resina composta nos dentes 14, 16, 24, 25, 26, 27 e 46; crie dentria estava presente nos
dentes 36, 37 e 47. Relatou-se hipersensibilidade dentria. O tratamento incluiu coroas de
zircnia totalmente sinterizada para todos os dentes, usando um sistema CAD-CAM. Nenhum
problema de adaptao marginal das coroas foi detectado e os resultados finais foram
satisfatrios para ambos o paciente e o clnico.
Concluso: A reabilitao clnica de amelogenesis imperfecta um desafio e a abordagem
multidisciplinar deve ser mandatria. As coroas de zircnia so uma excelente opo para
a reabilitao de pacientes com esta anomalia, pois o opaco dos copings de zircnia pode
mascarar as diferentes cores dos pilares e o resultado final esteticamente aceitvel, com
biocompatibilidade e propriedades fsicas superiores.
Palavras-chave: Amelogenesis imperfecta; coroas; cermica de policristais de zircnia
tetragonal estabilizada pelo trio; esttica dentria

Correspondence:
Joo Carlos Sampaio Fernandes
Faculty of Dental Medicine of the University of Porto
Rua Dr. Manuel Pereira da Silva
Porto Portugal
4200-392

Received: April 5, 2009


Accepted: June 5, 2009

Rev. odonto cinc. 2009;24(3):323-326

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CAD-CAM all-ceramic fully sintered zirconia crowns

Introduction

Third Appointment

Amelogenesis imperfecta comprises a unique group of


hereditary alterations that result in abnormal enamel
development. Teeth are more prone to wear and breakage,
resulting in unsatisfactory esthetics, dental sensitivity,
and loss of vertical dimension, which frequently requires
extensive dental treatment (1,2). The oral rehabilitation of
this pathology poses a clinical challenge for practitioners,
and a multidisciplinary approach is often mandatory.
While dental genetics rules the definite diagnosis, dental
rehabilitation may include conservative procedures, such as
direct restorations, or may evolve to Fixed Prosthodontics
and occlusal treatment to achieve results with good esthetics
and function.
New dental ceramics have been increasingly used for allceramic crowns and fixed partial dentures. Zirconia is an
excellent ceramic material with mechanical properties
similar to those of noble and base-metal alloys used for
cast restorations; for this reason zirconia is sometimes
named as ceramic steel (3). Fully sintered zirconia may
reach flexural strength values as high as 1,200 MPa, and
a 1:1 accuracy is achieved as sinterization contraction
does not exist. However, the fabrication of restorations
in fully sintered zirconia is time consuming and complex
in the laboratory, thus partial sintered zirconia is more
used (3-5). Also, zirconia is biocompatible, promotes
low bacteria adhesion, has colors similar to natural teeth,
and it is opaque, which is desirable to treat dischromic
teeth (3,5), such as those found in cases of amelogenis
imperfecta.

Dental impressions were made with a polyvinylsiloxane


material (putty and light material, Express 3M, USA) using
a double-mix single step technique. A gypsum model (Kavo
Everest Rock Kavo, Germany) with individual dies was
created.
Dental Faculty Lab Work
Every single tooth was scanned in a CAD-CAM scanning
unit (Kavo Everest Scan Control 4.07.06, Kavo, Germany).
In the virtual model obtained the dental technician designed
zirconia copings using the Kavo Everest CAD software
(v.4.07.06) with the following dimensions: 0.55mm of
thickness (B), 0.3mm in the marginal line (A), and 0.5mm
in the transition area (X). The designed copings were milled
in a CAM unit (Kavo Everest) using fully sintered zirconia
blocks (ZH blanks Kavo Everest, Germany) (Fig. 3).
Fourth Appointment
All copings were tested to check their adaptation to the
respective abutments, and no marginal gaps were detected
(Fig. 4). Although a plaque control program was established,
the patient still had generalized gingivitis.
Fifth Appointment
Fully sintered zirconia copings were veneered and the obtained
crowns were tested and cemented over the abutments with
a resin cement (RelyX Unicem Self-Adhesive Universal
Resin Cement 3M, USA). Final results were satisfactory
in relation to esthetics and function (Fig. 5, 6).

Case Description

Discussion

A male, 28 year-old patient sought dental treatment at


the Fixed Prosthodontics Clinics of the Faculty of Dental
Medicine of the University of Porto, Portugal, presenting a
clinical condition compatible with amelogenesis imperfecta.
At clinical examination, all teeth had yellow, brown, and
white areas characteristic of weakened enamel. Composite
restorations were present on teeth 14, 16, 24, 25, 26, 27,
and 46; dental caries were present on teeth 36, 37, and 47.
Hipersensitivity also was reported (Fig. 1).
The treatment planning included fully sintered zirconia
crowns for all teeth to protect dental structure, reduce
sensitivity, and improve esthetics and masticatory function.
The patient had bad oral hygiene, and a plaque control
program also was established. All treatment procedures
were performed by dental students under clinical faculty
supervision.

The present dental literature is scarce in relation to clinical


reports of fully sintered zirconia copings. Although the
flexural strength values are higher than that of partially
sintered zirconia, this type of work is very time and
material (burs) consuming for the dental laboratory, and
a robust machining system is necessary (7). It is expected
a machining time of 8 hours per 4 units, which totalized
52h for the present case. Additionally, the efficacy of the
milling burs is reduced every 2 to 3 single units processing,
and frequent replacement is needed. The main advantage of
this type of ceramic block is that a 1:1 accuracy is obtained
with the machining procedure, since the ceramic is already
sintered, which improves crown adaptation. However, some
previous studies (4,5) reported that pre-sintered zirconia
blocks may be an alternative option for this type of complete
oral rehabilitation with less laboratory work in relation to the
time and materials consumed. Also, a recent review by Denry
and Kelly (6) highlighted that some questions still remain
about the zirconia surface topography after hard machining,
while soft machining would provide better final results.
At the end of the treatment, function and esthetics were
improved, and the patient was satisfied. An optimum
result could not be achieved due to the fact that the patient

First and Second Appointments


Teeth 17-27 and 36-46 were prepared for full ceramic crowns
with a shoulder finish line during two dental appointments.
Provisional crowns (Tab 2000; Kerr Italia SpA, Salerno,
Italy) were cemented with a temporary cement (Temp-Bond
Kerr Espaa, Spain) (Fig. 2).
324

Rev. odonto cinc. 2009;24(3):323-326

Sampaio Fernandes et al.

still had gingivitis, despite the established plaque control


program and placement of provisional restorations over
two endodontic treated teeth (37 and 47). According to
Macedo (7), amelogenesis imperfecta may be associated
with generalized gingival enlargement, although this finding
is unusual. The patient with amelogenesis imperfecta can be
treated with direct composite restorations, but clinical cases
presenting large and generalized loss of dental structure
would benefited from complete oral rehabilitation with fixed
prostheses (1,8-10), specially all-ceramics crowns (8), which

may provide good esthetics, biocompatibility, and improved


physical properties for several years.
In conclusion, zirconia crowns are an excellent option for the
rehabilitation of patients with amelogenesis imperfecta. The
opaque feature of the zirconia coping masks the dischromic
abutments, and the final results are esthetically acceptable.
Furthermore, the CAD-CAM fully sintered zirconia had no
problems concerning marginal adaptation of the crowns,
but the laboratory procedures are more complex than that
of pre-sintered zirconia.

Fig. 1. Patients initial condition: amelogenesis


imperfecta, and gingivitis due a poor oral hygiene.

Fig. 2. Preparation of teeth 17-12, 22-27,


33-36 and 43-46, in the first appointment.

Fig. 3. Zirconia milled copings in the


abutment models.

Fig. 4. Copings placed over the abutments. Patient had


deficient plaque control with associated gingivitis.

Fig. 5. Full ceramic crowns


(veneered fully sintered zirconia copings).

Fig. 6. Final result


of the zirconia crowns cemented
(front view and panoramic x-ray)

Rev. odonto cinc. 2009;24(3):323-326

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CAD-CAM all-ceramic fully sintered zirconia crowns

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